DISTRICT SCHOOL BOARD OF PASCO COUNTY STUDENT HEALTH INFORMATION FORM

(To be completed for initial registration and for change in health status) Student School Date Last Name First Middle Student # Grade DOB Sex: Male Female Does your child have any of the following health conditions or concerns? 1. Allergy to any foods, medications, or insects? Yes No If yes, list

Reaction: Mild Severe Needs: Epipen Benadryl

2. Asthma or wheezing? Yes No

If yes, please indicate if uses nebulizer: Yes No If yes, how often?

If yes, please indicate if uses inhaler: Yes No If yes, how often?

3. Diabetes or high/low blood sugar? Yes No If yes, list medication/treatment

4. Epilepsy or convulsion/seizure? Yes No If yes, list medication/treatment

Date of last episode

5. Recent hospitalization? Yes No If yes, reason Date

If yes, reason Date

6. Heart murmur or history of heart condition? Yes No If yes, explain

7. Serious burn or broken bone? Yes No If yes, explain

8. Ear infection or draining ear? Yes No If yes, explain

9. Trouble hearing? Yes No Wears hearing aid: Yes No

Should be wearing hearing aid: Yes No

10. Trouble seeing? Yes No Wears glasses or contacts: Yes No

Should be wearing glasses or contacts: Yes No

11. Major head injury or concussion? Yes No If yes, explain

12. Kidney or bladder problems? Yes No If yes, explain

MIS Form #442 Rev. 5/13

DISTRICT SCHOOL BOARD OF PASCO COUNTY

STUDENT HEALTH INFORMATION FORM (To be completed for initial registration and for change in health status)

13. Frequent bed-wetting? Yes No If yes, explain

14. Stomach or bowel problems? Yes No If yes, explain

15. Trouble sleeping? Yes No If yes, explain

16. Hernia or rupture of groin or navel? Yes No If yes, explain

17. Trouble with teeth? Yes No If yes, explain

18. Anemia or low iron? Yes No If yes, explain

19. Attention Deficit Disorder (ADD/ADHD) or hyperactivity? Yes No If yes, explain

20. Mental health concerns? Yes No If yes, explain

21. Difficulty understanding dangerous situations, wanders or runs away from adults? Yes No If yes,

explain

Please list any other medicine taken regularly and dosage: Are there any special health procedures that should be followed at school? Are there any limits on your childʼs participation in physical education or recess activities due to a health condition? If your child is Medicaid eligible, please provide Medicaid number and name of

the Medicaid Insurance Plan .

Print - Parent/Guardian Name Parent/Guardian Signature Date DISTRIBUTION: This form will be placed in your childʼs cumulative record.

MIS Form #442 Rev. 5/13 - Back